Author: Charlotte Pell

Human by default

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By Jeremy Cox

Today’s faulty thinking about digital technology in service organisations is rooted in a dim view of human nature and an over-optimistic view of automation. Managers typically think of staff as ‘resources’ and automation as a means of reducing costs by replacing people with machines and latterly digital technology. Digital is cheaper, faster, more reliable and more modern… it’s just better, isn’t it?

Sadly, expectations are often confounded when technology makes things harder rather than easier for customers and staff, and renders work processes more cumbersome than before they were automated. E-enabled IT helpdesk requests produce multiple rework loops to clarify a problem, where before an expert and user would sort it out in direct conversation. Document imaging and workflow systems in both public and private services such as benefits, insurance claims or mortgage sales create fragmented, inflexible processes that paradoxically slow down the work, multiply failure demand and reduce revenue, all contradicting management’s assumption that automation would have the opposite effect.

Defaulting to digital in services for reasons of cost is a trap. Instead, we must learn to put technology to work for us and our services – explicitly designing it to complement human activity and enhance value creation. Counterintuitively, this turns out to be the route not only to improved service, revenue and morale, but reduced costs as well.

The origins of faulty thinking

Where does the prevailing attitude to automation come from? Can understanding the origins of the digital obsession help us to frame a better approach?

A century ago, industrialisation triggered the emergence of the ‘command-and-control’ management archetype, with Henry Ford, F.W. Taylor and Alfred Sloan of General Motors among notable pioneers. In grappling with the challenges of building large, complex mass-production manufacturing enterprises, they were instrumental in formulating two critical pillars in subsequent thinking about management and automation: the ‘machine view’ of work’, and the separation of decision-making from that work.

The ‘machine view’ of work sees industrial processes through a reductionist lens as simple, stable and repeatable. Adam Smith’s observation of ‘the division of labour in pin manufacturing, and the great increase in the quantity of work that results’, is illustrated on the reverse of a British £20 note, and this mechanistic perspective has been subconsciously internalised by most managers. In his 1978 Harvard Business Review article ‘Where Does a Customer Fit in a Service Organisation?’, Richard Chase applies the machine view to service, setting out the necessity of isolating customers from the delivery of work. A customer-facing ‘front office’ is used for intake, allowing work to be processed as standardised and automated ‘factory work’ in a ‘back office’ for maximum efficiency.

The separation of decision-making from work makes management responsible for planning, directing and controlling the work of front-line staff who are treated as passive recipients of management orders – a Taylorist construct that has come to seem normal and unremarkable. Managers spend their time in meetings making decisions using aggregated measures and arbitrary targets, planning and orchestrating change top-down. Functional hierarchies keep decision-making removed from the reality of front-line customer-facing work and the experience of real customers.

We default to digital

Both ideas have made the leap from manufacturing to service and dominate management thinking in service organisations to this day. Managers constantly strive to reduce costs by replacing human activity with top-down imposition of standardised automated processes.

Customers are encouraged, and increasingly coerced, to transact online and self-serve. We are ‘channel switched’, through the use of physical menaces (‘you need to check in at the kiosk’), financial penalties (extra charges for transactions with humans) or withdrawal of service (queries can only be submitted online). The initial digital-access-only design for the Universal Credit programme unravels as the reality of dealing with vulnerable people with multiple interrelated issues dawns.

The NHS Connecting for Health programme was a multi-billion pound debacle rooted in the erroneous assumption that technology is ‘just better’ and therefore the point of departure for a transformation programme. Commercial organisations from banks and insurers to utilities and telecoms firms have all introduced technology-driven front-office/back-office designs with digital channels at the front end and IT-driven back offices that produce slow, expensive and poor service.

We have all experienced situations of technology degrading our experience and causing frustration, delay, confusion, and repeat demand, in the process discouraging us from coming back to spend more. The machine metaphor of work is simply incompatible with the true nature of service provision. Health and social care, financial and emergency services, social housing organisations, utility companies and charities do not manufacture millions of identical pins – their challenge is to absorb an almost infinite variety of demand and create value for customers for each of whom ‘what matters’ is something quite different.

Standardisation, functionalisation and automation can disastrously undermine an organisation’s ability to meet those challenges. The separation of decision-making from work compounds the ‘machine view’ problem by making managers blind to the reality of the issues customers and staff alike experience.

There is a clear alternative

The hopeful alternative is to reframe our approach to technology. We should consider it as something that should be designed to complement rather than replace human activity. Putting technology to work in service organisations means learning to listen to customers and understand what matters to them on an individual basis, and learning to absorb variety. By using that as a starting point for better services design, we can leverage technology to work in our favour. At my squash club I can book courts online, over the phone, and in person at the club reception. Sometimes I have a complex request with multiple overlapping bookings and different people paying for courts, and a conversation works best. At other times I’m happy to do all the work myself online; the system can absorb variety and do what matters for me at different times.

An insurance company client found that re-integrating responsibility and decision-making into front-line work and switching the role of management from controlling to supporting staff led to reductions in fraud. Staff were better able to identify suspicious transactions when dealing with live demand than the previous script-driven automated systems. Similarly, levels of fraud in a benefits system fell when expert staff switched (under their own initiative) from back-office processing to face-to-face support and assessment with customers. In both cases, IT was then used to track background patterns and flag suspicious cases for investigation – an example of value-driven, human-by-design customer processes, with technology configured to complement rather than control.

While Airbnb, Uber, and Amazon are notable examples of technology enabling real benefits to customers and disrupting older market models, to consider them as a justification for ‘digital-by-default’ is to miss the point – instead they reflect the way technology can be exploited to better meet what matters to customers. Airbnb and Uber don’t work without good drivers and hosts. The technology complements human activity rather than replacing it.

Putting technology to work

Our inheritance of outdated and inappropriate mass-production thinking has led to a pessimistic view of human nature and an over-rosy view of automation. ‘Digital-by-default’ thinking prevails in service organisations, but the idea of using technology to put people out of work is ripe for consignment to the dustbin of history. Shifting the perspective to one of ‘human by default, put technology to work’, is a profound and to many counterintuitive idea.

‘Putting technology to work’ entails first building service organisations that recognise and respond to what matters to customers. It entails systematically enabling staff to create value for customers. It entails managers and staff learning and improving together to create service systems that absorb variety. Then and only then should technology be pulled to add more value to the delivery of service and truly act as a complement to human activity.

Read similar articles in Edition Three of The Vanguard Periodical: The Vanguard Method and Digital. Ask for your FREE hard copy or PDF.

 

 

Having IT your way

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By John Little

It’s a significant and neglected challenge for service leaders: distinguishing problems they actually have to solve from those they think they have or have been persuaded by others to believe they have.

The push to digitise services has been encouraged by government and large IT outsourcers, often in a Whitehall partnership. They promote the notion that digitising services also makes them cheaper, faster and better. Not so. Many outsourced IT providers have little knowledge of what good IT support looks like to meet individual organisations’ operational needs, and frankly often don’t care. They just want a sale.

When implemented, dysfunctional IT architecture and software effectively dictates what service staff can and can’t do to meet a user’s needs. Senior leaders often deny this happens… unless and until they go into the work to see for themselves, at which point, ‘This isn’t what I thought we had bought. It needs to be changed,’ is a frequently heard lament. ‘The vendor said it was “configurable”, so I guess we just need to reconfigure it’.

Few large organisations now write or maintain their own IT software. Like service work in general, IT development has been outsourced to software houses with their own standardised product offerings and profit-focused sales agenda. Very often the only things retained in the IT department are the minor technical assistance function, contract management and a few peripheral activities. They have thus voluntarily down-skilled themselves into product administrators – a self-inflicted helplessness often compounded by effective ‘capture’ of IT support departments by vendors and their products. The effect is to lock in inflexible and wasteful systems sometimes for a decade or more.

As for configuration: whatever vendors promise in sales negotiations, the reality is that after implementation, off-the-shelf software is almost impossible to reconfigure except at a cost that most organisations will not want or be able to afford. Reconfiguring a ‘vanilla’ product often entails persuading other purchasers, whom you don’t know and who don’t know or care about your business, to agree to software changes that will affect all users. Not surprisingly, this doesn’t usually end well.

How to do it wrong

A housing organisation, let’s call it AB Housing, was looking to upgrade its IT in support of a newly completed business improvement project.

AB Housing hired an expert in PRINCE II project management on a ‘temporary’ basis to help it source and implement appropriate software. The project manager supposedly knew about the PRINCE II framework but not very much about IT itself, nor about AB’s IT requirements. He struggled to comprehend the business needs as the work progressed but couldn’t let that show. He was an expert, after all, who needed to work with other clients after this project ended.

The PRINCE II approach to software development appears systematic and orderly. It is based on seven principles, seven themes and seven processes – what could be more reassuring? Just to be sure and to comply with best-practice, the project manager insisted on a risk register which was duly drawn up, with a list of imagined/made-up risks, all categorised, named and given a risk number. Needless to say, when the IT project collapsed, none of the things that caused it to fail figured on the risk register. The reason was that the project leaders, who understood neither the work nor the staff who did, were themselves the source of most of the risk.

The temporary ‘expert’ now believed everything was in place for full project control.

The project launched with a project board, senior responsible owner, project manager, steering committee of potential users (no one spotted the irony here – why not start with actual users?), and a senior external IT expert available on call.

Although no one on the project board had been involved with the business improvement project, its members were expected to sign off on staged implementation proposals on the basis of what they were told the IT would do to deliver the improvement. This brought their individual biases and opinions into play and triggered much debate. The senior responsible owner had not taken part in the business improvement project, being considered too busy and senior, so a second external IT expert was drafted in for another opinion. Benchmarking trips to see systems of other clients were arranged, but no actual users of the system were included.

In parallel, the project management expert was ensuring that the PRINCE II documentation of ‘milestone review meetings’ was being properly recorded. What could possibly go wrong?

I know you want a happy ending to this story. You will be glad to know there was one.

The matter was resolved by terminating the services of the PRINCE II and external IT experts. Having adopted a Vanguard Method approach, the senior leadership realised that the initial business improvement project and findings were flawed. They were flawed because they were based on customer focus groups, asking managers what they thought, staff workshops and ‘away days’.

So leaders went back to first principles and established what was actually happening on the ground and why. They then learned what they could do to meet service users’ needs in the most effective, efficient and consequently economical manner. The supporting software-writing expertise and solution were then ‘pulled’ to the real future solution within the organisation. The solution was what is known as a Rapid Application Development (RAD) approach. It is hated by off-the-shelf IT snake-oil salespeople.

The staff who carried out a rapid ‘check’ and were therefore aware of just how bad the existing IT systems were now had knowledge to take forward into a redesign. After two weeks of prototyping the redesign team decided they needed software code-writers to work alongside them to learn what an effective IT system should look like and be able to support them with. Coders then worked iteratively with the team to create software that followed the logic and flow of the work.

Understanding the need for measures relating to purpose, the code-writers ensured that the data required for capability charts was available as a matter of course rather than as an afterthought.

When it was rolled-In to the workforce the EDIPing of staff was so much easier because the work-flow-focused IT had been designed in support of the work.  Staff could get the measures they needed when they needed them.  Because AB Housing owned and controlled the code it was as cheap as chips to make any amendments that were necessary.

How to do it right

This example describes how Norwich-based Flagship Housing Group built its own bespoke IT system to ensure seamless interaction across the interlinked systems in its repairs and maintenance service. To do so, it decided to bring the service under direct control through its own specially created subsidiary, RFT Services.

This came about because Flagship’s chief executive and two directors took the time to participate, along with a cross section of staff, directly in the ‘check’ or understand phase. It was a professionally life-changing experience for all of them. What they discovered by seeing it for themselves was that performance was very different from what they had been led to believe. With real knowledge of the ‘what and why of performance’, they could see that there was a great opportunity to provide services in a much more effective and efficient manner.

Much of the underperformance established in ‘check’ was caused by the standardised, off-the-shelf, so-called best-practice IT in use by Flagship and its outsourced contractors. There was a compelling case for a complete rethink of the delivery model and specifically the IT systems for repairs and maintenance. This included a significantly greater understanding of the grim state of the logistics support to tradespeople in outsourced contractors.

As the ‘redesign’ phase progressed, the directors realised that having the right IT to support and integrate their requirements in terms of leadership, logistics, operations and tradespeople was absolutely pivotal to achieving their goals of as near as possible perfect service delivery.

Nothing on the market met their specific software requirements. Like many other organisations, Flagship realised that its own internal software writing abilities had been eroded over the years. It had bought the line chorused by many senior IT managers that writing your own software is too expensive. The answer to that of course is, ‘compared to what?’ They have no idea of the waste and associated costs driven in by buying standardised systems. Initially, Flagship needed help from an outside IT supplier to build a system to its specific need. Concurrently the company began to rebuild its internal IT capability to ensure self-sufficiency and sustainability in the longer term – a smart and counterintuitive move.

At the end of it, Flagship had in place a bespoke IT system that was a key enabler of its ability to deliver service right first time. The system is still being developed in an emergent manner and that will continue. This is all at a fraction of the cost of traditional dysfunctional IT maintenance systems available on the market. There are none of the requirements to take unwanted software updates that make off-the-shelf IT providers such huge undeserved profits.

What does the new IT look like?

When a repair is reported, it is recorded and visible on the system which is then fed into the workload management facility.

This makes it accessible to those who need it, in the format they need and at the time they need it to deploy resources. It enables them to understand and plan organisational capacity against what tenants actually demand. The tradesperson attends at the time the specified by the tenant, not the housing organisation. Resource controllers have full visibility on where tradespeople are and what demands still have to be met, enabling frontline leaders to deploy effectively in their support.

Meanwhile, materials used in the repair are recorded on the system. The visibility on usage of materials by trade and location and building archetype allows the Flagship logistics centres to replenish van stocks in a timely manner. As with initial coding, early logistics learning work was supported by an outside company called Perfect Flow. However, the Flagship logistics staffs are now self-supporting. Crucially, their element of the Flagship IT system is fully integrated with the rest of the business, allowing the cost of the repair to be calculated when the job is closed. This is fed directly into the logistics element of the IT system so that business intelligence is acquired, in emergent fashion, on product usage and performance, in turn feeding into more effective and economical purchasing and supplier selection.

The prospects for IT in service organisations is bright – so long as it is approached in a user-oriented, purpose-focused manner. The future should not be to line the pockets of outsourcing providers, nor to sustain the UK as a centre of incompetence in IT project management. It should be to ensure IT serves the public and staff in the most effective and economical fashion.

It is essentials to know what problem(s) you are actually trying to solve with IT; indeed, if you have one at all. Because there is something new and shiny in the marketplace doesn’t mean your organisation has to have it. IT must be fit for purpose – your purpose – not some compromise that ends up cutting you off from customers.

As at Flagship, senior leaders must be actively involved in the entire ‘understand, improve and implement’ cycle. This ensures those with authority can make properly formulated and informed choices regarding what fit-for-purpose IT consists of for their organisation.

Service staff must not be captured and constrained in how they serve customers by the IT system. Standardised IT-based transactions always cost more, in our experience, driving in failure, waste and unanticipated overall cost. Cheap is usually dear. Yet having useful and useable IT is both achievable and necessary. Bespoke can deliver what you need when you need it how you need it. As in the case of Flagship, well designed, purpose-focused IT is a significant part of that bright future – provided you do it your way.

John Little

 

 

Leading change

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By Denise Lyon

WANTED! Managers who are curious, resilient – and willing to challenge their own thinking first

If you look at the job description of senior managers in any public sector organisation, you will find a long list of requirements – pages of necessary skills and knowledge, which applicants will have to prove and evidence to get the job. From managing staff to monitoring a project, from assessing risk to staying within budget, the list goes on and on.

Then there’s attitude and aptitude. Is it followability, intelligence and tenacity that are top of the list? Or is it integrity, common sense and a dash of derring-do?  Maybe it’s all of these and a few more. The more you think about it, the longer the list becomes.

What do we know about good leadership?

So can we make this a simpler proposition?

When organisations take their first steps in rethinking their approach to the design and management of services, we help them get clear on the kind of leaders they will need to navigate through the change. What is it in leaders that will allow a fundamental shift in organisational thinking and perspective to take place? What sort of person will be able to:

  • Challenge their own thinking with a willing heart
  • Put in the hard work to change it
  • When the going gets tough, keep their eye on the prize – much better service, much lower cost?

 
Here’s what we know.

Open-minded and curious

In the words of the great Frank Zappa, ‘A mind is like a parachute. It doesn’t work if it isn’t open.’ This is absolutely key when it comes to choosing leaders. People recruited to senior posts are not necessarily selected for this trait, and it is important to establish quickly who has it and who is stubbornly focused on defending territory and status quo. The latter will not make a good leader of change, nor indeed in good leader in the new world afterwards.

Truly curious people, if you have them, will make excellent leaders of the system.  A ‘follow-me-and-do-what-I-say’ leadership model is unhelpful and potentially destructive because it concentrates responsibility in one person and absolves others from taking initiative and ownership of problems. Someone who works with people to genuinely understand the issues getting in the way of great service and then resolve them is the kind of leader required.

Strong and resilient

The yin and the yang of transforming a service means there will be highs and lows to contend with. Studying a service as a system uncovers truths about customer experiences that are sometimes uncomfortable and hard for managers to accept. Letting go of long-held management beliefs (‘Targets are good, aren’t they?’ ‘No, they are not, and we will help you understand why!’), takes a robust personality who is willing and able to get over the shocks and move on. As Katharina Haase, Chief Operating Officer at Barclaycard Germany said at the Leaders Summit in March 2016:

You need to change a lot of stuff, be brave about it.

Confronting the waste and inefficiencies a leader has unwittingly introduced into their service design is probably not going to make for their best ever day.

The upside, though, is the joy of ‘getting it’: understanding how to design more efficiently to meet and manage demand, a Eureka moment that will have the convert (and their customers) grinning from ear to ear.

They will also ‘get’ what to measure in order to gauge to what extent the organisation is meeting its purpose, as defined from the customers’ point of view. Owen Buckwell, Head of Housing and Property Services at Portsmouth City Council explains:

It makes your organisation thermostatic. In other words it routinely changes according to how your customers’ demands change.

Good measures help to pinpoint where to focus improvement efforts and quantify their impact when you do. Leaders also learn to ask good questions as Karime Hassan, Chief Executive and Growth Executive of Exeter City Council says:

It’s far more focused and disciplined so that the questions I ask of my managers and the questions I ask of the staff are far more pointed.

Hands on and a bit bossy

Senior people are used to delegating. They need to be good at it to stay sane and keep on top of a demanding job. But here’s the rub. The only way to change a mindset is to experience something personally. Think of it this way: it is no more possible to delegate understanding your service as a system than to delegate learning how to swim. In practice, this means that a leader must stop doing something else in order to free up the necessary time, so a conversation about re-prioritising the work is an important early step. It is essential to get in the pool. Or in the world of service, in the work. Not to do the work, but to study what’s happening in the work, using the Vanguard Method.

Albert Einstein hit the nail on the head when he said, ‘We cannot hope to solve the problems we have created with the thinking that created them’.  Before making any sustainable transformative steps, leaders need to get hands on and understand how their current thinking led to the current service design and delivery.

The brain makes a transformative leap, as Richard Hiscocks, Casualty Claims Director at Aviva UK, found:

Once you realise you’ve been wrong about everything it’s really hard to go back.

Once they do get it, there will be much to do to completely redesign how the service is delivered. This is where it helps to be assured and assertive – even, dare we say it, a little bit bossy. Redesigning to meet demand may entail major actions such as renegotiating contracts, introducing new roles and agreeing different corporate priorities. A well-informed and assertive leader on the case is essential.

So maybe we can make those job descriptions even simpler.

Vacant:

An uncomfortable but rewarding job

Wanted:

An open-minded, resilient, hands-on leader who is willing to challenge their own thinking.

 

 

 

System conditions: a powerful lever for change

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By Jo Gibson and Brendan O’Donovan

Although providers of public services would mostly proclaim a primary commitment to their service users, the unfortunate truth is that a study of the system from the citizen’s point of view reveals a very different reality. Despite best efforts from dedicated public sector workers and well-meaning leaders, getting a service can often resemble an obstacle race or negotiating a maze.

The maze is a system problem, not a people problem. Many public sector systems have evolved a warped view of their purpose in response to external and internal pressures. As a result of these pressures, organisations often lose sight of what happens to the citizen on the receiving end.  Much to everyone’s frustration; service users, staff and leaders alike, organisations become focused around the needs of the regulator, the commissioner or central government.

Whether the service is life insurance, road maintenance or domiciliary care, we should always start from a deep understanding of what matters to the individual receiving the service. It involves taking a person-shaped rather than an organisation-shaped view of the citizen’s needs, or in Vanguard terms working from the ‘outside-in’. There is thus no better illustration of the principle in action than in what we’ve broadly termed ‘people centred services’ (i.e. public or third sector services such as health and social care, housing, benefits and policing). Importantly, viewing these systems in this way allows us to identify and eventually remove what we call ‘system conditions’.

Why system conditions matter

System conditions are the things that explain why a system behaves in the way it does. They form the framework within which those delivering any service have to operate. They are important for three reasons:

  • They shape performance, positively or negatively
  • Sustainably improving a process is rarely possible without changing the system conditions that frame it
  • As manifestations of flawed management thinking, system conditions point to the strongest lever for change in the system – altering the way people think about the design and management of work

 
Some system conditions are present in any service: for example, the use of measures. What is measured and how, will dictate how a system will work (‘what gets measured gets managed’). Often measures are imposed as arbitrary targets. A classic is the four-hour wait time target in hospital accident and emergency (A&E) departments. The intent of the measure is to help manage perceived high demand for urgent medical treatment. In fact, it leads to people either cheating the figures or cheating the system: for instance, holding patients on trolleys in corridors or in ambulances having first seen a triage nurse and thus officially falling within the four-hour target. This is a great example of what is termed a single-loop solution to a complex problem. Of course, ‘doing things better’ is a classic single-loop solution to a complex problem. A double-loop solution would be ‘doing better things’, in this case working to understand the true nature of demand and then design a system capable of reliably managing it. As those who have studied A&E demand know, most (up to 80%) is demand that shouldn’t be there in the first place and only presents there because other parts of the end-to-end system are not working as they should.

We have clients who, having understood the true nature and frequency of demand, have been able to redesign the whole system to remove much of the repeat and inappropriate demand altogether. This has the effect of releasing system capacity to focus on getting it right first time for the individual. Improving individual resilience leads to correspondingly reduced demand and resource pressure on the service.

Organisational roles and structures are another ever-present system condition. In most people centred services, the system is structured so that an individual’s life is split into segments, each handled by a different professional specialist. In a simple adult social care system this involves many contacts, with the citizen required to tell their story at each one. In one case, an individual was obliged to repeat their history more than 200 times in two years. This is not exceptional; indeed it is ‘designed- in’ in current systems, governed as they are by a perceived imperative to manage cost by embedding costly professional expertise deep in the system where its use by the patient or service user can be strictly rationed. Reaching these professionals means undergoing repeated assessment and referral – often ending with treatment refused on the grounds that ‘your condition is not serious enough … (yet)’.

The alternative is a service structured around the whole individual citizen, with a focus on understanding and responding to their life priorities. Some leaders are reshaping services to remove splits between functions, sometimes even barriers between organisations. To enable this real integration, the purpose of the service is redefined to relate directly to what matters to the citizen and helps them to lead the life they want. New operating principles ensure that they only have to tell their story once and a single individual is assigned to work with them throughout.

Substantial change depends on ‘a vital few’

There are many other system conditions, including performance management and incentive and reward schemes, reporting requirements (to ‘feed the machine’), demands of IT, standard policies and procedures, the commissioning process, and regulation and inspection. Yet in any one case substantial change normally depends only on ‘a vital few’. A common one is decision-making remote from the work and abstracted from the end-user’s context. A good example in people centred services is the Department of Health’s Continuing Healthcare (CHC) funding process for people who need ongoing personalised health and care to ensure either a good quality of life or in some cases a good quality end of life.

Under the current system, to get funding requires two 124-page assessments to be carried out, one by a nurse and another by a social worker. A panel then sits every 6-8 weeks to decide. In one health service studied, out of an annual total of 400 cases only 10 were refused on initial presentation; eventually, after much delay, all the cases were agreed and funded. Predictably, the information received by the panel is incomplete and has to be chased up. The governing CHC framework makes it clear that funding decisions should be wholly based on need and not on funding and budget. If that is the case, why have a decision-making process disconnected from the work? From studying the current system, it is clear that, in reality, money is the biggest driver, and the logic behind the design is the need to control spending to meet the budget. Not only is the design an utter waste of time and resource, it removes decision-making from those with knowledge and understanding in the work.

One health and social care system decided to remove this system condition. Instead it is experimenting with the revolutionary idea of letting the workers make the decisions, freeing up time spent on paperwork actually to meet the individual face-to-face and jointly work out what good care for them should look like. The key worker for the case is responsible for understanding the individual’s complete end-to-end story and, with support from an integrated team, for taking informed joint decisions with the individual as to proportionate support. No longer are decisions about care taken by a group of people disconnected from the work and with no knowledge of the individual circumstances. The worker is trusted to do the right thing based on understanding, continuity and trust.

Another system condition responsible for much failure of service to meet people’s real needs (and often make them worse rather than better) is standardisation of response. In current people centred services response to demand is prescriptive and based on pre-set standards. In adult social care this manifests itself in a prescribed assessment of need carried out by a social worker, with standard questions which may or may not have relevance to the person and their needs. On that basis the social worker decides what support, if any, will be forthcoming, in the shape of a care package consisting of up to four calls a day, their timings determined by staff workloads, travel distance and time, rather than what matters to the individual. One consequence is that people who, with the right kind of support, could perfectly well live independently become dependent on the calls. In other words, the care package is over-specified. Or the care package fails to meet the underlying need and breaks down, eventually resulting in hospitalisation. Analysis of hospital demand reveals that this under-specification scenario is played out with depressing regularity.

In some redesigned services, starting from a different set of principles, the organisation delves into the need behind the demand by taking time to conduct a ‘what matters’ conversation. Once a bond of trust and understanding is established, the task is to help the individual help themselves, by identifying with them their strengths and capacities, along with those of their family and community networks. We call this ‘designing against demand’. In people centred services, the value work consists of listening to and understanding a patient/service user’s needs as the only way of understanding real demand and planning an appropriate and effective response.

Removing system conditions: a lever for change

Although it is vital to understand system conditions, we don’t recommend that you start there. We believe system conditions are best understood as the causes of waste. Their importance emerges from the process of studying performance – you learn what prevents and enables services to be truly person-centred. Understanding the biggest causes of waste leads you to the ‘vital few’ that offer the greatest leverage for change.

Identifying and removing, or at least containing, the constraints imposed by system conditions is essential to developing a more effective service. It allows the service to be redesigned around the individual citizen, and enables the organisation to devote its energies and time to understanding and responding to what really matters to them.

Joanne Gibson
Brendan O’Donovan

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

 

 

 

 

It is what you do and the way that you do it, that gets results

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Much as I enjoy Ella Fitzgerald’s 1939 recording of ‘T’ain’t What You Do (It’s The Way That You Do It)’, reinvigorated by The Fun Boy Three with Banarama in 1982, it’s not entirely right. Ella probably wasn’t singing about this, but in terms of running service organisations, it absolutely is about both what and how. What service organisations are here to do (their purpose) is inextricably linked with how they do it (what matters) – they are two sides of the same coin. If we want to build thriving communities with people living good lives, and when the time comes dying good deaths, then first we need to understand the ‘what and how’ from the perspective of citizens/patients/customers (from now on referred to as people).

T’aint what you do

So how do organisations typically go about understanding their ‘what and how’ from the people’s perspective? There are three common approaches:

The ‘It’s-always-been-like-this’ or ‘There-is-no-alternative’ approach

One approach is that they don’t go about trying to understand people at all. Instead they do what they (or usually their regulators, politicians, shareholders, other stakeholders) want, however they want to do it. Their actions are often well-intentioned but disappointingly ineffective from the perspective of the people.

The ‘Words-speak-louder-than-actions’ approach

Another approach is to say they listen to the people, and sometimes make expensive attempts to do so, but ultimately they actually carry on as they always have.

The ‘Design-against-demand-and-what-matters’ approach

This approach is all about listening to what people are really saying about what they fundamentally need and how they need it, and then doing just that.

Which approach is likely to be the most effective, in the sense of maximising the satisfaction of people and staff while simultaneously lowering costs? Hint: it’s the third. If you’re not convinced, spend an hour or two listening to the people wherever they interact with your organisation and consider a) how often they interact because of something the system has failed to do, or failed to do properly, for them; b) the steps involved in dealing with that interaction; c) the cost of those interactions and steps.

It’s the way that you do it

I’m assuming that the first two approaches are familiar. As in, ‘Of course we listen to people, our poster says we do, as does the recorded message we play before people can talk to us, and the online surveys we ask people to complete, and the complaints team we’ve put in place, and the people engagement groups we run. Oh, and we’ve got a CRM system’. Engaging with people has never been such big business. And yet this is where Ella is right, it is the way that you do it that gets results. Some typically misconceived ways to do it:

  • Regarding engagement as an end-in-itself. We’ve engaged; the box has been ticked. It’s the organisational equivalent of a student asking their teacher ‘Will this be in the exam?’ Rather, engaging is a means to an end, the end being understanding what people fundamentally need from us and how they need it, and then actually doing it.
  • The methods used to engage do not enable us to understand the ‘what and how’ from the people’s perspective. For example:
    • They ask leading and/or closed questions. In effect, what they say is, ‘Tell us about what matters to us (not what matters to you), in a way that’s easy for us to report on’.
    • They believe (maybe) that ‘people engagement groups’ (a handful of people who can spare the time, sitting around a table once in a while, sharing their opinions) are a legitimate means of informing organisations about what people (all people) need.
  • Confusing effectiveness with efficiency (see also article on p XX). For example, ‘The more people we can (be seen to) engage with, the better. IT will help us do that more quickly, easily and cheaply. Let’s use Twitter to ask people what they think’. This is to mistake quantity of response for quality of understanding and thereby getting neither. Social media is just as much about building relationships as old-fashioned face-to-face methods. Without those relationships (how many of us have a meaningful online relationship with an organisation about our lives, let alone one we are prepared to share publicly?), you may as well be shouting into an empty room. The ceaseless march towards digitalisation, driven by the flawed assumption that it’s more efficient (ie cheaper), has blinded us to the reality of its limitations.
  • Misrepresenting and/or misinterpreting what people say (see points above) and using it to maintain the status quo and impose service-led solutions. If you don’t really listen, or choose not to, you don’t really hear. A less amusing version of The Two Ronnies’ ‘Four Candles’ comes to mind.
  • Even the most effective understanding is meaningless if nothing (good) is done with it. Using understanding to design and manage your system is the logical, but often missing, next step.

 
That’s what gets results

So, if perfunctory and ineffective understanding of purpose and what matters leads to sub-optimal performance, what’s the alternative? How do we optimise performance to build thriving communities and resourceful individuals? Where do we start? By going to the places in our organisations where people interact with us and listening to what they say. In their words, write them down, don’t précis them. Do it until you don’t hear anything new. Identify the themes and use them to shape your purpose and understanding of what matters. It should tell you everything you need to know but, if more detail is needed, ask people directly what matters to them using non-leading, open questions. Have a dialogue, the old-fashioned way. We humans are quite good at that.

The beauty of doing this is that it’s right there, in the work, freely available, part of the day job, not a bolt-on exercise undertaken at great expense. It’s full-strength, real-time, comprehensive knowledge. Just like sitting by a fire, there’s no substitute for proximity. You can’t sit in another room and ask someone else to sit in front of the fire for you, and expect to feel the benefits. Understanding serves two purposes, both of which enable informed choices about what action to take next. First, it provides valid data. Second, it affords you the opportunity to unlearn old, dysfunctional assumptions and beliefs about the design and management of work, and learn about new, optimal thinking. That’s not something that can be delegated.

Real understanding is the prerequisite to taking action using better (optimal) principles. That’s what gets results.

Resource

http://beyondcommandandcontrol.com/thinking-things/

Emma Ashton

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

 

Resolving the efficiency paradox

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Jeremy Cox, Vanguard Consulting

Public-sector organisations across the spectrum are faced with the apparently conflicting challenge of making efficiency savings while simultaneously delivering on a vision of building safer, healthier and more economically resilient communities. I want to deliver an optimistic but counterintuitive message: to improve efficiency, the last thing a leader should do is to focus on efficiency. Understanding this paradox is the first step to delivering great public services at the lowest possible cost.

The efficiency paradox

For managers at all levels, this goes completely against the grain. Surely it is the manager’s role to maximise the productivity of their unit or organisation? Yet when we study past efficiency-boosting attempts, we find that, notwithstanding the good intentions, they routinely have the opposite effect. Thus:

  • Call-handling has been centralised into a single point of contact, yet rising caseloads in the back office prevent costs from coming down
  • To protect expensive professional resource (planners, benefits assessors, social workers, clinical staff…) the process is functionalised and screening and admin tasks allocated to lower-grade staff; but constant backlogs mean there is little overall benefit
  • Managers in the highways department put pressure on repair crews to do more jobs per day, so how come the number of defects in the road network keeps rising and only the high priority jobs get done?

 
Why is the direct focus on efficiency counterproductive? Because efficiency is an effect, a by-product, not a cause. When we learn to see efficiency as an emergent effect of doing the right things right, rather than an objective to be achieved directly, the way forward becomes clear.

Neurology – from efficiency to effectiveness

The neurology department of an acute hospital had been trying for years to reduce length of stay for stroke patients – an effort straight out of the efficiency paradigm. Using the Vanguard Method, the department shifted its focus to purpose (swift recovery) and the smooth flow of value work (diagnosis, treatment and rehabilitation) through the end-to-end hospital system.

The shift in leadership thinking from efficiency (‘reduce costs by reducing length of stay’) to purpose and value led to dramatically reduced mortality rates, fewer admissions to non-specialist wards, freed-up bed capacity, and improved staff morale. And guess what happened to the problem they were trying and failing to solve in the first place? Length of stay shrank, turning a ‘loss’ per patient for the hospital into a surplus.

Cameron was in the efficiency trap

By contrast, here is David Cameron in a speech in September 2015:

…Businesses are always looking at ways to streamline their functions so they can become more effective. I would argue it’s an imperative – a moral imperative – for government to do the same. When money is tight, it’s simply unforgivable to waste taxpayers’ money.

But then he walked straight into the efficiency trap:

…Take our emergency services. Right now we have a situation where in most towns, the police, fire and ambulance services all have different premises, back offices, IT policies and systems, and procurement policies – despite all their work being closely related… Places like Hampshire have shown the way forward, where the emergency services have brought functions together to save millions of pounds a year. We need to see that sort of thinking in other places.

Nothing in the ‘shared services’ approach is about understanding or improving the system’s ability to do useful work or achieve purpose related to citizens. Sharing services is a crude attempt to gain efficiency through scale, under the mistaken assumption that all demand coming into the service and all the work done in response to it is of value. In fact these systems are full of failure demand (non-useful work), and their failure to deliver improved service is well documented.

I worked with a local authority which redeployed half of its HR capacity after designing for value in much the same way as the stroke service, completely transforming the service. If you knew you could drive efficiency from effectiveness in this way, would you try to make it more efficient by sharing?

Turning it around

Consider the knotty issue of how to deal with individuals and families who present repeatedly with demands that aren’t serious enough to be treated urgently. In studies across police, local authorities and healthcare, 40% of overall demand typically comes from people with a combination of issues (depression, alcohol, debt, housing, childcare, domestic violence) but who are consistently screened out, referred on or only given symptomatic help because they are ‘below threshold’ or ‘not our responsibility’.

For example, a family may have been referred by police to a domestic violence team but can’t get mental-health support until alcohol problems are dealt with; meanwhile school is applying pressure over class attendance, Job Centre+ has sanctioned benefits after a no-show, and the social landlord is pursuing arrears. Each agency attempts to make itself efficient by focusing rigorously on its own remit, but because the family situation is never addressed in the round, the demand just keeps coming.

The overall effect is that this ‘below-threshold’ group amplifies demand and cost across all agencies. Between half and three-quarters deteriorate over time, eventually triggering the need for ‘high-end’ services. Thus the efficiency focus costs everyone more in the long run, and it is no surprise that total demand into health and social care services is growing.

To turn this around requires a shift in focus from organisational efficiency to effectiveness from the citizen’s perspective. For the organisation, new assumptions for the design and management of work are key. Leaders have to set up and protect multi-agency intervention teams able to meet the various needs of ‘below-threshold’ individuals and families in their own context, and realign budgets, boundaries commissioning and governance accordingly. Where they do this, demand and costs fall, health and wellbeing improve, staff see greater value in their work and communities benefit.

It can be done – so do it

Ultimately this is an optimistic story, for two reasons. First, to make the difference we don’t need to replace all the managers or outsource services to the private sector. Everywhere I go I find dedicated, hard-working managers trying earnestly to build safer, more resilient communities and help individuals live better lives, who are hamstrung by conventional organisational thinking about efficiency and trapped in roles that require them to attend to the wrong things.

Second, designing and managing work from a different perspective is something that can be learned. The shift from managing efficiency to leading for effectiveness is what Vanguard is all about. Thus, a client in adult social care eliminated a persistent backlog and reduced the volume of wasteful casework in the system by 50% overnight by making just this shift, helping staff to redesign the work to focus on value, and constantly testing and learning using measures of what matters to service users.

In short, there is a way out of the efficiency paradox. When we learn to see that doing things right always makes things cheaper, and trying to improve efficiency always costs more, we deploy new methods for the design and management of work. So where will you start tomorrow?

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.